Basic Information
| Provider Information | |||||||||
| NPI: | 1376872895 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN HOME CARE SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 N WHITTINGTON PKWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402225186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023942100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1124 SAM RITTENBERG BLVD STE 8 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294073362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023942100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2009 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | WHOBREY | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 5026307249 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | EX0899 | 05 | SC | MEDICAID |